Chikungunya Virus: History, Geographic Distribution, Clinical Picture, and Treatment.

Chikungunya fever (CHIKF) is a re-emerging mosquito-borne disease caused by a virus endemic to Africa and Asia. Due to the ease with which its vectors propagate, the virus has spread to India and Europe, and more recently it arrived to the Caribbean, eventually extending into North, Central, and South America. According to the World Health Organization (WHO), the most common clinical manifestations are abrupt fever, polyarthralgia, headache, maculopapular rash, myalgia, and nausea/vomiting. Severe joint pain and stiffness have been known to incapacitate some patients from a few days to several months after infection. Fatal cases are rare, but some individuals have been known to develop severe forms of the disease that include neurological and cardiac complications and severe cutaneous manifestations. Additionally, there have been reports of infected mothers miscarrying and newborns that were infected in utero being born with congenital illnesses. Advanced age and various comorbidities have been associated with severe or atypical forms of CHIKF. Currently there are no approved vaccines for the chikungunya virus (CHIKV), and treatment aims to alleviate patient symptoms. The re emergence of the CHIKV and its spread to new places around the globe encourage the development of new preventive, diagnostic, and treatment options.

Sex Disparities in Ischemic Stroke Care: FL-PR CReSD Study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities).

BACKGROUND AND PURPOSE: Sex-specific disparities in stroke care including thrombolytic therapy and early hospital admission are reported. In a large registry of Florida and Puerto Rico hospitals participating in the Get With The Guidelines-Stroke program, we sought to determine sex-specific differences in ischemic stroke performance metrics and overall thrombolytic treatment. METHODS: Around 51 317 (49% women) patients were included from 73 sites from 2010 to 2014. Multivariable logistic regression with generalized estimating equations evaluated sex-specific differences in the prespecified Get With The Guidelines-Stroke metrics for defect-free care in ischemic stroke, adjusting for age, race-ethnicity, insurance status, hospital characteristics, individual risk factors, and the presenting stroke severity. RESULTS: As compared with men, women were older (73±15 versus 69±14 years; P<0.0001), more hypertensive (67% versus 63%, P<0.0001), and had more atrial fibrillation (19% versus 16%; P<0.0001). Defect-free care was slightly lower in women than in men (odds ratio, 0.96; 95% confidence interval, 0.93-1.00). Temporal trends in defect-free care improved substantially and similarly for men and women, with a 29% absolute improvement in women (P<0.0001) and 28% in men (P<0.0001), with P value of 0.13 for time-by-sex interaction. Women were less likely to receive thrombolysis (odds ratio, 0.92; 95% confidence interval, 0.86-0.99; P=0.02) and less likely to have a door-to-needle time <1 hour (odds ratio, 0.83; 95% confidence interval, 0.71-0.97; P=0.02) as compared with men. CONCLUSIONS: Women received comparable stroke care to men in this registry as measured by prespecified Get With The Guidelines metrics. However, women less likely received thrombolysis and had door-to-needle time <1 hour, an observation that calls for the implementation of interventions to reduce sex disparity in these measures.

Gender disparities in Puerto Ricans hospitalized with an initial acute myocardial infarction: A population-based perspective.

OBJECTIVE: The published literature suggests differences in presenting symptoms for acute myocardial infarction (AMI), management, and outcomes according to gender and age. However, limited information exists on this topic among Hispanics. METHODS: In Puerto Rican patients hospitalized with an initial AMI, we examined differences in presenting symptoms, effective cardiac therapies, and in-hospital mortality as a function of gender and age groups. We reviewed the medical records of patients hospitalized with a validated AMI in 12 greater San Juan, Puerto Rico hospitals during 2007. RESULTS: The average age of 1,415 patients hospitalized with a first AMI was 66 years and 45 % were women. Chest pain (81%) was the most prevalent acute presenting symptom with significant differences in its frequency between women (77%) and men (85%)(p<0.001). Right arm pain, shortness-of-breath/dyspnea, and sweating/ diaphoresis were most prevalent in patients 55-64 years old (45%), compared with patients 75 years and older (29%)(p<0.005). Relative to men and patients < 55 years old, coronary angiography/thrombolytic therapy and percutaneous coronary interventions were used less frequently in women and older patients (>75 years old). During hospitalization for AMI the in-hospital death rate was higher in women (8.6%) than men (6.0%), and increased with advancing age (p<0.05). CONCLUSION: These findings suggest significant gender and age differences in presenting symptoms, management, and early mortality in Puerto Ricans hospitalized with an initial AMI. It remains of considerable importance that health care personnel become aware of these gender and age differences to improve the management and outcomes of these patients.

[The University of Puerto Rico Emergency Medicine Program: 15th anniversary, its history and contribution to health care in Puerto Rico]. / [Programa de Medicina de Emergencia de la Universidad de Puerto Rico: decimoquinto aniversario, su historia y contribucion al cuidado de la salud de Puerto Rico]

Emergency medicine is a newly created specialty in Puerto Rico. The first training program began in 1977. Unfortunately this program was decertified by ACGME in 30 July 30 1993. On June 1, 1994 thanks to support of UPR School of Medicine new training program began. The program began using as a main clinical training site the PR Medical Center Emergency Room until 1995. Since that date the Hospital UPR, Dr Federico Trilla became its main clinical training site. Since its inception the program has graduated 116 emergency physicians, with more than 60% working in PR. The department's contribution to health care in Puerto Rico has been and will be based on the achievements of its faculty, residents and alumni. Approximately 25% of emergency rooms directors in PR are graduates. About 27% of graduates have subspecialties. It is also important to note that graduates of the program have helped to improve the quality of health care offered in emergency rooms in the country.

Bariatric surgery patients: reasons to visit emergency department after surgery.

STUDY OBJECTIVE: Morbid obesity prevalence is reaching epidemic proportions in Western society. Long-term weight loss can be achieved by bariatric surgery. This surgery also has a positive impact in the reduction of obesity related co-morbid conditions. The purpose of this study is to determine the reasons that bariatric surgery patients had to visit the emergency department within a three month period after surgery. METHODS: A retrospective chart review study was performed at the UPR Hospital in Carolina. Patients with the diagnosis of morbid obesity who had bariatric surgery were identified. Of the 283 patients who met the criteria, the following information was obtained: gender, age, height, weight, pre-operative BMI, obesity-related comorbid conditions, post operative length of stay (LOS), and reasons and length of stay of Emergency Department (ED) visits within a 3 month period after surgery. Statistical analysis was done with Statistical Package for Social Sciences (SPSS) Program. RESULTS: The same profile of gender and BMI was obtained between the population that had the surgery and the sample that visited the ED, the group of patients between 20-29 years old was more likely to visit the ED. No correlation was found between a longer post operative length of stay and an increased probability of visiting the ED. Of the population, 5% had to visit ED within a three month period. The most common post operative complications were: Abdominal Pain (46.2%), Emesis (38.5%), and Dehydration (30.8%). Other less frequent complications were nausea, DVT, pneumonia, dizziness, gastritis, infected wound and upper GI bleeding. CONCLUSION: The most common reasons that bariatric surgery patients had to visit the emergency department within a three month period after surgery were: abdominal pain, emesis, dehydration and nausea. These complications could most likely be attributed to patient poor compliance with diet, resulting in the classical symptoms of the dumping syndrome which is common in patients that have undergone bariatric surgery.

Descriptive study of cerebrovascular accidents among Hispanic population.

BACKGROUND AND PURPOSE: Data characterizing stroke patients among Hispanic population are scant. The aim of this study was to describe this population and to assess baseline knowledge of stroke type, risk factors, and family history, among others. METHODS: A retrospective chart review of 253 stroke patients admitted to the University of Puerto Rico Hospital during the fiscal year July 2002 to June 2003 was done. A standardized data collection form was used to obtain the following information from patient records: patient age, gender, stroke type, time of symptom onset, patient risk factors, family risk factors, and patient outcome. RESULTS: We enrolled 253 patients, 120 (47%) males and 133 (53%) females. Patient age distribution was as follows: 18 (7%) were < 44 years, 79 (31%) were bwtween 45-64 years, 156 (62%) were > 65 years. Stroke type distribution was: ischemic 174 (69%), hemorrhagic 49 (19%), and transformation from ischemic to hemorrhagic 13 (5%). Ischemic stroke subtypes distribution was: large-artery occlusion 113 (65%), small-artery occlusion 60 (34%), cardio-embolism 1 (0.6%), 17 (7%) information was not recorded. Time of symptom onset: 153 (60%) > 3 hours, 14 (6%) < 3 hours, and 86 (34%) was unknown. Family history of risk factors was present in 103 (41%), not present 29 (11%) and 121 (49%) was unknown. Most common patient risk factors were: hypertension 212 (84%), > 65 years 156 (62%), male gender 120 (47%), diabetes mellitus 105 (42%), previous history of stroke 91 (36%), hyper-cholesterolemia 44 (17%), history of smoking 51 (20%), alcoholism 43 (17%). CONCLUSION: The data obtained from this Hispanic population is similar to that reported in the literature for the general population. The prevalence of ischemic strokes out numbered by far the occurrence of hemorrhagic strokes in the study group. Both men and women demonstrated an increasing tendency of stroke incidence with increasing age. Among death outcome, a difference was evident in the > 65 age group, showing an increase in women fatality compared to men. Hypertension was the most prevalent risk factor. This study will serve to build a database for future reference, thus providing an evidence-based foundation for treatment, therapy improvement, and patient care.

The use of therapeutic hypothermia after cardiopulmonary arrest.

Actually recommended by the International Liaison Committee on Resuscitation (ILCOR), therapeutic hypothermia has been the only modality shown to improve neurological outcomes after cardiac arrest. This article provides the background for such recommendations as well as: pathophysiology, review of brain injury during cardiac arrest, discussion of beneficial effects of therapeutic hypothermia, different mechanisms used to induce it and the latest clinical trials results.

University of Puerto Rico Emergency Medicine Program: impact throughout the country.

OBJECTIVES: Determine distribution, job description, and board certification status of the University of Puerto Rico Emergency Medicine Program (UPREMP) graduates. METHODS: A telephone survey was performed of all UPREMP graduates from 1995 to 2007, asking for the following information: practitioner or non practitioner, working place, job description (e.g. Fellow, Staff or Emergency Room Directors), and board certification status. In cases in which the person could not be reached by phone, the last information available at the UPREMRP department was used to fill the survey. The board certification was verified using The American Board of Medical Specialties web site. Worksheets were used to organize data and then analyzed statistically with Excel 2003. RESULTS: Of the 102 graduates, 59% are males and 41% are women, 50% are board certified, 30% are not and 20% are pending certification. Of the female graduates, 77% are board certified, while only 60% of male graduates are board certified. Sixty percent (60%) of the graduates stayed in Puerto Rico and 40% moved to the United States. The distribution of graduates among PR senatorial districts (counties) was as follows: San Juan 22%, Bayamón 17%, Arecibo 0%, Mayagüez 5%, Ponce, 23%, Guayama 6%, Humacao 12% and Carolina 20%. The job description among graduates was: 54% full time Emergency Department (ED) Staff, 3% part time ED staff, 23% academic faculty, 10% directors, 5% fellows and 5% other. CONCLUSION: From our study, we can conclude that although the vast majority of UPREMP graduates stay in PR after graduation, most of them practice in four of the eight PR senatorial districts. Further studies are needed to determine: the reasons why graduates have moved to the mainland US and for working mostly in four PR senatorial districts.